Participants

Mark Miller; Chief Investor Relations Officer; Encompass Health Corp

Mark Tarr; President, Chief Executive Officer, Director; Encompass Health Corp

Douglas Coltharp; Chief Financial Officer, Executive Vice President; Encompass Health Corp

Pito Chickering; Analyst; Deutsche Bank

Whit Mayo; Analyst; Leerink Partners

Matthew Gillmor; Analyst; KeyBanc Capital Markets Inc

Ann Hynes; Analyst; Mizuho Securities USA LLC

Joanna Gajuk; Analyst; Bank of America

Brian Tanquilut; Analyst; Jefferies LLC

AJ Rice; Analyst; UBS

Jared Haase; Analyst; William Blair

Andrew Mok; Analyst; Barclays Capital Inc

John Ransom; Analyst; Raymond James

Presentation

Operator

Good morning everyone and welcome to Encompass Health's first quarter 2025 earnings conference call. (Operator Instructions) Today's conference call is being recorded. If you have any objections to potentially being recorded, you may disconnect at this time. I'll now turn the call over to Mark Miller, Encompass Health's chief investor relations officer.

Mark Miller

Thank you, operator, and good morning, everyone. Thank you for joining Encompass Health's first quarter 2025 earnings call. Before we begin, if you do not already have a copy, the first quarter earnings release supplemental information and related Form 8-K filed with the SEC are available on our website at www.encompasshealth.com.
On page two of the supplemental information, you will find the safe harbor statements, which are also set forth in greater detail on the last page of the earnings release. During the call, we will make forward-looking statements such as guidance and growth projections which are subject to risks and uncertainties, many of which are beyond our control.
Certain risks and uncertainties like those relating to regulatory developments as well as volume, bad debt and cost trends that could cause actual results to differ materially from our projections, estimates, and expectations are discussed in the company's SEC filings, including the earnings release and related Form 8-K. The Form 10-K for the year ended December 31, 2024, and the Form 10-Q for the quarter ended March 31, 2025, when filed.
We encourage you to read them. You are cautioned not to place undue reliance on the estimates, projections, guidance, and other forward-looking information presented, which are based on current estimates of future events and speak only as of today. We do not undertake a duty to update these forward-looking statements.
Our supplemental information and discussion on this call will include certain non-GAAP financial measures. For such measures, reconciliation to the most directly comparable GAAP measure is available at the end of the supplemental information, at the end of the earnings release, and as part of the Form 8-K filed yesterday with the SEC, all of which are available on our website.
I would like to remind everyone that we will adhere to the one question and one follow-up question rule to allow everyone to submit a question. If you have additional questions, please feel free to put yourself back in the queue. With that, I'll turn the call over to Mark Tarr, Encompass Health's President and Chief Executive Officer.

Mark Tarr

Thank you, Mark, and good morning, everyone. We are pleased to report another strong quarter. First quarter revenues increased 10.6% and adjusted EBITDA increased 14.9%. First quarter, total discharge growth of 6.3% was a strong result, particularly in light of Q1 2024's 10% discharge growth.
Recall that Q1, 2024 benefited from an extra day due to leap year and because the quarter ended on Easter Sunday. First quarter of 2025, same store discharges grew 4.4%. Once again, the efforts of our dedicated and highly competent clinical team allowed us to accommodate this volume while maintaining outstanding patient outcomes.
Our Q1 discharge community rate was 84%, our discharge to acute rate was 8.9%, and our discharge to sniff rate was down to 6.4%. Our performance on each of these quality metrics compare favorably to the industry average. We continue to invest in our clinical team by providing professional growth and development programs such as our clinical ladder and in-house continuing education opportunities.
These programs contribute to the continuing improvement in our clinical turnover trends. Q1 of 2025 annualized RN turnover was 20.1%, down from previous years, 20.4%, and annualized therapist turnover rate was 6.3%, down from prior year 7.7%. Due in large part to our Q1 results, we are increasing our 2025 guidance. Doug will go into greater detail in his comments.
Demand for Earth services remains strong, and we are continuing to invest in capacity additions to meet the needs of patients requiring inpatient rehabilitation services. In Q1, we opened a new 40-bed joint venture hospital in Athens, Georgia, our seventh JB Hospital in partnership with Piedmont.
We also added 25 beds to existing hospitals. Over the balance of the year, we plan to open six De Novos with a total of 300 beds, as well as a 50-bed free-standing satellite hospital. Consistent with our historical practice, the satellite will be accounted for as a bed edition. We anticipate adding another 125 to 145 beds to existing hospitals in 2025, inclusive of the aforementioned satellite.
We continue to build and maintain an active pipeline of De Novo projects, both wholly owned and JVs while also monitoring and assessing bed expansion opportunities. Our pipeline of announced De Novo projects with opening dates beyond 2025 currently consists of 10 hospitals with 500 beds, and we anticipate additional projects will be announced over the balance of the year.
In response to strong volumes and current occupancy levels at some of our hospitals, we have increased our bed expansion plans and now expect to add approximately 120 beds to existing hospitals in both 2026 and 2027. The demand for inpatient rehabilitation services remains considerably underserved and continues to grow as the US population ages.
We intend to continue to expand our capacity and capabilities to help meet this need. On April 11 of this year, CMS released the 2026 Earth proposed rule. This included a proposed net market basket update of 2.6%, which we estimate would result in a 2.7% increase for our Medicare patients beginning October 1, 2025 based on our current patient meds.
Based on historical practice, we expect the Earth's final rule to be released in late July or early August. Yesterday we announced that Pat Tuer has been promoted to the newly established position of Chief Operating Officer where he will oversee hospital operations across the organization. Pat's promotion was prompted by our significant growth and robust development pipeline.
Since joining Encompass Health in 2018, Pat has held several leadership roles, most recently, group President overseeing three of our geographic operating regions with a total of 69 hospitals. Pat has been instrumental in shaping our operational success and driving the delivery of exceptional care to the patients and communities we serve.
Many of you met Pat at our investor day in 2023 and at investor conferences and meetings since then. And we're excited to have him in this new role. He's with us here in the room this morning. Now I'll turn it over to Doug.

Douglas Coltharp

Thank you, Mark, and good morning, everyone. Revenue for the quarter increased 10.6% to $1.46 billion, and adjusted EBITDA increased 14.9% to $313.6 million. Revenue growth for the quarter was driven by a 6.3% increase in total discharges and a 3.9% increase in net revenue per discharge. Same store discharges grew 4.4%. Our volume strength continues to be broad-based across geographies and patient and payor mix.
Net revenue for discharge growth of 3.9% was higher than anticipated due in part to payer mix. Q1 SWB per FTE increased 3.2%. Premium labor cost comprised of contract labor and sign on and ship bonuses declined $5 million from Q1'24 to $28.6 million.
Contract labor in the quarter was $16.4 million, down $2.9 million from Q1'24, and sign on and ship bonuses were $12.2 million ,down $2.1 million. Contract labor FTEs as a percent of total FTEs was 1.3% for the quarter. Consistent with our recent trend, benefits expense for FTE increased 14%. Growth in benefits expense for FTE is being driven by an increase in the severity and frequency of group medical claims.
Root medical expense growth is expected to remain elevated in Q2 and begin to ease in the second half of the year as we anniversary the increase experienced in 2024. It's also worth noting that Q1's benefits for FTE increase comes off a low base as benefits for FTE growth in Q1 of 24 was 0.7%. Net reopening and ramp up costs were $2.1 million.
As previously stated, we expect these costs to be heavily weighted towards the second half of the year due to the timing of our new hospital openings. Q1 adjusted free cash flow increased 32.7% to $222.4 million. We now expect full year adjusted free cash flow of $620 million to $715 million. Our primary use of free cash flow continues to be capacity expansions.
As Mark mentioned, given the growing demand for Earth services and our increasing occupancy rates, we have increased our pipeline of bed addition projects. This is reflected both in our raised growth-related CapEx assumptions for 2025 and our estimated bed editions through 2027. For 2025, we now anticipate adding 100 to 120 beds to existing hospitals. For '26 and '27, we now anticipate adding approximately 120 beds to existing hospitals.
During Q1, we repurchased 333,679 shares of our common stock for a total of $32.1 million and declared a cash dividend of $0.17 per share. Our leverage and liquidity remain well positioned. Net leverage at quarter end was 2.1 times compared to 2.2 times at year end. We ended the quarter with $95.8 million in unrestricted cash and no amounts drawn on our billion dollar revolving credit facility.
Moving on to guidance, as Mark stated, based primarily on our Q1 results, we are raising our 2025 guidance as follows. Net operating revenue of $5.85 billion to $5.925 billion. Adjusted EBITDA of $1.185 billion to $1.220 billion and adjusted earnings per share of $4.85 to $5.10. The key considerations underlying our guidance can be found on page 11 of the supplemental slides. With that, we'll open the lines for questions.

Question and Answer Session

Operator

(Operator Instructions)
Pito Chickering, Deutsche Bank

Douglas Coltharp

Hey Pito.

Pito Chickering

Hey, good morning, guys, great quarter. First question here on, it's been a long time since we've seen such a big move up in Medicare fee for service. Is this due to any strategic actions that you guys have put in place, or something else? But he added such a nice revenue per discharge in the quarter.

Douglas Coltharp

Yeah, Peter, your observation is absolutely correct. As a matter of fact, we haven't seen Medicare fee for service discharges grow faster than Medicare Advantage discharges since the middle of 2022, and it was somewhat of a surprise to us. It is not the result of any deliberate strategic actions in which we're favoring referrals or patient admissions from fee for service versus Medicare Advantage.
We, like the rest of the world, have heard anecdotally about the fact that perhaps MA growth based on new enrollment may have slowed a little bit, but we really don't think that that was having a discerning impact on the mix for the quarter.
One trend or one quarter is not a trend make. So we're not necessarily anticipating that this is the new normal on a go forward basis. As a matter of fact, our revised guidance assumes that we get back into the kind of payer mix dynamic that we were seeing prior to this quarter, but it's certainly something we'll keep an eye on.

Mark Tarr

Peter, just a reminder, over 9% of our admissions come directly from the acute care hospitals referral sources in our marketplaces, so. No, we don't know if this is a major trend or not, but we were pretty much just there to try to service the referral sources that are existing in our marketplaces.

Douglas Coltharp

And it is interesting if you look at the pair mix in totality for the quarter. And even with the reversal in terms of the trend between fee for service and Medicare Advantage, Medicare care fee for service and Medicare Advantage together as a percentage of our payer mix increased about 150 basis points, and those are our two highest reimbursement payers.
And then Medicaid and managed care, which are below that in terms of reimbursement, declined by about 140 basis points. And so it was those factors that really contributed significantly to the 3.9% increase in revenue per discharge.

Pito Chickering

Okay, great. And then, can you talk about your employee's preoccupied bed and occupancy. It's a high class problem, but your occupancy hit a new high and your employees preoccupied bed hit a new lows provided a lot of leverage on the P&L.
Are you guys sort of behind on hiring with the current demand, or is this a seasonal, and can you sort of give us the dynamics between occupancy, employees occupied by bed, and how you think about planning for hiring in the next few quarters due to demand and productivity? Thank you.

Mark Tarr

Yeah, Peter, we remain committed to that 3.4 number on EPOB. Clearly, we got some leverage in the first quarter, as you noted, that's the highest occupancy rate we've had. A couple of notes on that would be is remember we only had one de novo hospital came online in Q1, so you didn't have the delivering of the ramp up.
We will have obviously a higher number of De Novos coming on, particularly in the third and fourth quarters. So that's going to impact your EPOB as we bring on staff at those new hospitals that had not yet opened with patients. A we're, no, I don't think we're behind. We remain committed. We have the talent acquisition team that continues to hire, particularly focused on nurses, but they've done a great deal with other positions.
We did redirect some of those resources that were staffing new hospitals onto existing hospitals and markets where we continue to run a high percentage of contract labor that may have continued to, contributed to the decrease in the contract labor dollars you saw in the first quarter.
We're just able to fill more of those open positions at those hospitals with permanent staff versus contract labor. So, I wouldn't read a whole lot into the EPOB. We'll continue to focus on running as efficient as we can, but we still think the 3.4 number is a good number.

Douglas Coltharp

Peter, you hit on a couple of key relationships in that number. One is that there is some seasonality factored in Q1 is normally a very good volume quarter for us, and that proved to be the case this year as well. So there is some seasonality factored in. That said, I would say that overall the discharge growth in the quarter was higher than our initial expectations.
The second thing is that there's definitely a correlation between labor productivity and occupancy because you're creating patient density when you run at higher levels of occupancy, and that gives rise to coverage issues.
But to Mark's point, we're not anticipating that this is a new sustainable run rate, and when you factor in the seasonality in the business and the timing of new capacity additions through the course of the year, we expect that number to gravitate a little bit north.

Operator

Andrew Mok, Barclays

Douglas Coltharp

Hello Andrew.

Operator

Whit Mayo, Leerink Partners

Whit Mayo

Hey guys, good morning. Congrats, yeah, congrats to Pat. I guess my first question, I'm curious just there's a lot of conversation around tariffs and wanted to just get what your updated thoughts are on either supply cost or construction expenses. So I'll just start there.

Douglas Coltharp

Yeah, like probably everybody else in this country, we're a little bit in wait and see mode. We've done a pretty thorough assessment based on the information that is available to us, and it's obviously a very dynamic environment.
Right now we don't believe that we have much, if any, in the way of near-term risk either with related to construction costs or more generally speaking within our supply chain. Much of the material that is related to the projects that are currently under construction has already been procured and it hasn't been subject to any of the tariffs.
And within our broader supply chain, based on some of the reconfiguration that we originally did out of COVID, and based on the underlying contracts that are in place, we're fairly insulated against that at least for fiscal year 2025. We'll continue to keep an eye on this, but right now we're not any, we're not estimating any kind of significant impact.

Whit Mayo

Okay. And then, sounds like you guys are increasing a little bit the commitments on that growth and additions next year. Just was wondering if you had any initial expectations around startup costs for 2026 and also if you could just remind us on Medicaid supplemental sort of what the exposure is there. Thanks.

Douglas Coltharp

Yeah, I don't have an initial range for you on the '26 startup costs. My guess is that I'd have to look more specifically and compare timing from quarter to quarter and specifically look at what some of the timing around early 2027, but I wouldn't expect the number to be markedly different than what we're anticipating for 2025 into 2026.
In terms of the Medicaid supplemental payments, and as we've said previously for us, it's just not nearly as big a deal as it is for the acute care hospitals. I want to remind you of some of the historical context. If we go back to 2023, the total EBITDA impact for us from provider tax, revenue minus the provider tax expense was a negative $800,000. The year prior to in 2022 was a positive $2 million.
Last year was a bigger number with a $15.4 million impact, favorable impact on EBITDA, but even that pales in comparison to that which you're experiencing with some of the acute care hospitals. And for the quarter for Q1, the total impact was $33 million to EBITDA, which was a decrease of $1.9 million from the $4.9 million dollar EBITDA impact in Q1 of '24.

Whit Mayo

Great, thanks.

Operator

Matthew Gillmor, KeyBanc

Douglas Coltharp

Hey Matthew.

Matthew Gillmor

Hey, good morning guys, and congrats as well, Pat. Maybe going back to labor efficiency and asking about the SWB per FTE metric, it seemed like that, ran relatively modestly in the first quarter so favorable. I was curious how that played out versus your expectations and it sounded like from Doug's comments that labor and sign on and shift bonuses was favorable and I was curious sort of how you felt about the sustainability of that going forward.

Douglas Coltharp

Yeah, so you're absolutely right, at 3.2% in terms of the total SWB inflation rate for the first quarter, we were slightly below the low end of the guidance range that we had for the full year. The benefits piece being up 14% was pretty much in line with our expectations and again was consistent with the trend that we saw at least in Q4 of last year.
The points of leverage that got us below the low end of the range were twofold. The one you just mentioned was we had anticipated that across the course of the year, and we continue to have this anticipation that the total spend on the premium labor categories from '24 to '25 would remain essentially flat from a nominal dollar perspective and we saw year over year decrease.
We're not sure again that I know I've used this phrase already once today, but we're not sure that one quarter makes a trend. So we're still building into our guidance, the anticipation that flat is a good assumption. And then the second is that are just removing the premium labor categories are SW per FTE inflated at a more modest rate than we had recognized in the second half of the year.
Again, that we're not ready to call that a new trend, but it was a favorable outcome for the quarter.

Mark Tarr

And I just, I would say that I mean we have a history of running relatively low contract labor. Clearly the volume growth that we've had the past couple of years has put some upward pressure on that. But our operating teams are very focused on filling their full-time and part-time positions and continuing to drive down the need for contract labor and they have the tools to do that.
So as we continue to see some of the labor markets normalize or even soften a bit from where they were in previous years, we remain very focused on a driving down those numbers.

Douglas Coltharp

And we were pleased with the 1.3% of total FTEs being contract labor FTEs in the quarter. That's the lowest we've been at. In a while, I'll remind you that our run rate prior to the initial peak in labor conditions which really occurred in the third quarter of 2021, had been just below 1%. So we're not to that level. We don't know that we're getting back to that level.
The rate for contract labor also has really stabilized kind of in that $175 to $180,000 on an annualized basis. Again, that's higher than it would have been prior to this peak conditions rising in Q1 of '21, which was closer to $145 to $150,000 but it's substantially down from the peak which we hit in the first quarter of 2022, which was $240,000.

Matthew Gillmor

That's great. Thank you. And then one quick one on flu. I think in the past sometimes you've called out flu leading to more patients with debility coming to your facilities. Just curious if there was any of that impact in the quarter and anything to flag there.

Mark Tarr

I don't think there was anything that's material yes that seemed to be a pretty active flu season. The ability to measure that impact on our volumes for Q1, I think it's negligible, but It was out there, but I can't say it's any more significant or less significant than previous years.

Douglas Coltharp

Yeah, I think within the patient mix the strength was actually more broad based and wasn't driven as much by flu volume, and you actually see that in the fact that the ability, and you're correct, Matthew, that that's typically where you'll see some of those flu volumes show up and the ability on a year over year basis only increased 1.2% in the quarter. That good growth in stroke again at roughly 4%, brain injury was up 8%, neurological up almost 7%.

Matthew Gillmor

Got It. Thank you.

Operator

Ann Hynes, Mizuho Securities

Mark Tarr

Morning, Anne.

Ann Hynes

Hi, good morning. Just going back to the capacity because it was so high in the quarter and this to no strategy. What, obviously it's working and what at what point do you think you could or would want to accelerate your growth strategy? Do you think that's in the courage over the next couple of years since the strategy has been so successful?

Douglas Coltharp

Well, we are accelerating the growth strategy starting with the bed expansions, and that's the most direct way to alleviate any pressures arising from higher occupancy rates. I do want to point out that because we've been increasing steadily, these portion of our portfolio that is comprised of private rooms versus semi-private rooms, our theoretical occupancy rate has been increasing along the way.
To give you some specifics on that, if we go back to 2020, just over 40% of our total beds were in private rooms. At the end of the first quarter, 56% of our total beds were in private rooms. So that 78.8% occupancy rate that we experienced was the highest that we can recall ever having occurred.
And it does suggest that we need to accelerate some of these bed expansions over a multi-year period of time, which fortunately we have both the access to capital and the capabilities within our design and construction team to be able to do. With regard to accelerating De novo activity beyond the current range, that's got a longer lead time associated with it.
It's typically from the time we idea on a particular market to getting the doors open, it's about three years. As Mark alluded to in his comments, we would expect that through the course of this year we're going to be announcing additional De novo projects that will be opening beyond 2025.
But for the immediate time being, we believe staying in this range of 6 to 10 per year, perhaps trying to operate at the midpoint or higher is the appropriate place for us to be. And I'll remind you beyond just the spend and the demands on our design and construction team.
Each one of those hospitals has to be staffed with a trained clinical workforce at capacity of 50 bed hospitals running about 100 FTEs and about 2/3 of those are clinical. We want to make sure that we are adding capacity into this demand curve, which is very real out there, that we're doing so in a way that is also ensuring that we produce high quality patient outcomes.

Ann Hynes

Great. And just on guidance, obviously you'd be consensus by a healthy margin, and I know Doug, I think, I believe you said during the call is that volume is ahead of your expectations. What did you beat your internal expectations by? And I guess the guidance ranges versus the beat, is that just conservatism on your part, or is there something we should model that maybe the streets miss modeling through the rest of the year?

Douglas Coltharp

Well, that is a series of really loaded questions most of which you knew in advance I wasn't going to answer. The quarter was ahead of our expectations. I'm not going to give you a specific number on that, but I cited some of the specific areas where it was ahead earlier, which is we did a little bit better on volume than we anticipated.
And the two biggest upside surprises for us were that revenue for discharge based on the payer mix that we hadn't anticipated and then also the fact that we got a lot of leverage in the SWB line. Some of that was the EPOB coming down based on the higher volume and the occupancy rate, and some of it was the leverage that we got against premium labor. So certainly, that was a favorable outcome for Q1.
It's uncertain to us how much of that is sustainable for the balance of the year. And so we've maintained a lot of the annual assumptions that we had in the guidance considerations, another area of favorability, we were at the low end of the of the bad debt assumption right at 2%.
That owed in large part to the fact that we had only a de minimis amount of TPE activity during the quarter, and as we all experienced last year, we know that TPE audit activity can be very lumpy. And so we've left that assumption for the full year the same. It's only the first quarter. Obviously we'll be more informed about the sustainability of any of these trends after we are able to book another quarter.

Ann Hynes

Great, thank you.

Operator

Joanna Gajuk, Bank of America

Douglas Coltharp

Hi, good morning, Joanna.

Joanna Gajuk

Hey, morning. Thanks so much for taking that question. So, maybe on the demand where you spoke about a lot of online demand for the services where you, like you said, keep expanding your expansion plans. Right, so can you give us a little bit more there, are there some geographies that stand out or is it grow based?
Can you talk about maybe also competitive environment like why you're the only one, I guess, aggressively building and adding that?

Mark Tarr

Yeah, Joanne, this is Mark. I'll start. I'll say that the demand was across all geographies, as we have eight geographic operating regions and we saw nice growth in the majority of our markets and certainly across all those operating regions.
As we've noted before, I mean, we certainly benefit from the aging demographic, and I think that's exactly what we're seeing with non-discretionary patients and patients that have multiple comorbidities and issues that require first in large part acute care level care and then ready for inpatient rehabilitation care. So, the demand continues to grow closely linked to the aging demographic.

Douglas Coltharp

Yeah, to give you some specifics that we've cited before, if you look going backwards for more than a decade, the age cohort that is most served by us and by Earths in general has been growing at a keger of close to 4%. And over that same decade plus period, the total supply of earth beds in the US has increased less than 3% in total.
That's not a keger, that's total. So what already started as an inadequate supply of earth beds in this country widened substantially over that period. Why are, and we're not the only one who is adding capacity here. I think if you look at Select Medical, they've announced plans to substantially ramp up their capacity on the earth side as well. But perhaps the two of us kind of stand alone and why is that the case?
Well, it's really difficult to do this. First of all, it requires very substantial capital outlays to build a free standing hospital or even to add capacity to existing hospitals. We've mentioned before, we feel good about we've been able to stabilize the cost per bed on De novo construction at about $1.2 million. And even for bed expansions, the cost per bed now is north of $800,000. So the capital outlay is very extensive.
The clinical expertise is to treat these very medically complex patients is also a barrier to entry, as is the need for a robust compliance function. And one of the things that we really benefit from is the fact that we enjoy substantial economies of scale that allows us to get operating leverage across these platforms and also to extrapolate best practices.
So yeah, if it were if it were easy to do given the attractiveness of the market, we'd probably see a lot more capacity coming in, but that's just not the case. It is highly complex and expensive.

Joanna Gajuk

Right, exactly. Thanks for that. I guess related question on your bed expansions, right? So it sounds like, you expect or, generating more free cash flow, but then you also raising your bed expansion outlook. I mean, I guess it's portion but also by the occupancy being higher.
So should we expect the additional free cash flow to just go towards these bed additions? Can you remind us the returns you get on these, bed additions and maybe are contracted with De novo? Thank you.

Douglas Coltharp

Yeah, so consistent with our previous statements, the highest and best use of capital for us is on capacity expansions through both de novo and bet expansions, and bed expansions are the highest return of capital we have because we're leveraging components of the fixed infrastructure and we're building into a market where we already enjoy a presence and where the demand curve has already been established.
The occupancy rates are driving our decision to put more capital into the bed expansions. Fortunately, we have the capabilities again within our design and construction area to push forward some of those projects, as we and Mark mentioned in his comments, we've now run 11 straight quarters with same store growth north of 4%.
And so as a result, the pipeline of our hospitals that are qualifying for bed expansions based on their occupancy rates is increased. And so we're definitely going to give a prioritization with regard to capital allocation to adding capacity so that we're able to serve the needs of the patients in those markets. Thank you.

Operator

Brian Tanquilut, Jefferies

Brian Tanquilut

Hey guys, good morning. Congrats on the quarter. Maybe, yeah, Doug, maybe I'll follow up just on the comments you made to Joanna's question. So, as we think about some of these challenges that hospitals are staring down with DPP payments, probably going away or getting cut and whatnot.
Are you seeing anything in the market in terms of maybe either increased interest in partnering with you guys or the opposite where they're pulling back from plans to open earth that if that's the path that they were looking at just curious what you're seeing.

Douglas Coltharp

Yeah, I think it's the former. I think we continue to see more and more interest from various acute care hospitals about wanting to partner, and that's reflected in our in our pipeline. So, we continue to believe that probably at least half of De novos that will be opening over the next several years are likely to be in joint ventures. We get a great example again.
Mark mentioned in his comments. We've now got seven hospitals as part of the Piedmont joint venture. And that's the kind of success that really, I think, makes other acute care systems take notice of the effectiveness of these types of partnership relationships.

Mark Tarr

Hey Brian. So we also have a note. I mean there are a number of our existing partnerships, systems that currently have one or more rehab hospital JB with us that continue to look at their marketplace and as they expand their presence, they are also taking into account the needs for rebilitation.
So, you can look at Piedmont, our partnership and the St. Louis marketplace with BJC. Those are two examples of partners where we have multiple rehab hospitals as part of that overall relationship.

Douglas Coltharp

And I think what the acute care hospitals are increasingly aware of is that either a formal or an informal relationship with us in terms of having a freestanding herb in the market can increase their capacity in one of two ways.
One is we have demonstrated consistently that we have the ability to take highly complex medical patients out of the acute care hospitals earlier than other providers in their stay without in any way endangering the patient's recovery path. And so when we're doing that, we're allowing them to free up that bed more quickly.
The second of the more tangible way is when we use our model of going in and removing a unit from an acute care hospital and folding it into a free standing hospital so that space within the acute care hospital can be repurposed for general medical and surgical purposes and increase their overall capacity to address those patient needs.

Brian Tanquilut

Yeah, I appreciate that. And then maybe my follow up, Mark, as I think about, maybe an economic slowdown here, you guys have been there in in conference for a while and experienced previous recessions. Just curious how you're thinking about the durability of demand, and maybe Doug just to kind of layer onto this, any comment you can make on like exchange subsidy exposure just exchange exposure within your patient population. Thanks.

Mark Tarr

So I take first question. I mean, the demand for our services does not fluctuate with the economic status. I mean, it's, patients are non-discretionary and therefore, if you look back historically during periods of recession or high growth in the in the economy, it doesn't necessarily reflect and influence the need for our services. So I would not anticipate any decline in a recessionary economy.

Douglas Coltharp

And your second question, Brian, we have de minimis exposure to the exchanges.

Brian Tanquilut

Awesome thank you.

Operator

AJ Rice, UBS

AJ Rice

Hi, thanks everybody, talk to everybody. First, I guess on the benefit expense, I think you called out that it was up 14%. This is sort of the second quarter where you've called that out. I wonder how much of a headwind is that? I don't know if you size benefit as a percentage of your SWMB.
But it would be just interesting to know that and is there anything you can do, or you just have to wait for your anniversary that and then, it'll moderate as a pressure point or is there anything you can proactively do to manage that in a different way?

Douglas Coltharp

Yeah, so, first part of your question is benefits expense in total typically runs about 10% or 11% of total SWB. In terms of what we can do, we proactively work with our third party consultants, kind of assessing our trends versus broader trends within the US with large employers and specifically within the healthcare community.
We look at things like any changes to the composition of our benefits programs, the relationship between employee and employer responsibility, and so forth, and so on a regular basis we're making changes to those programs to try to contain the cost, but also to make sure that we're offering the most competitive benefits program we can from an employee's perspective because that's a big aspect of retention, and we'll continue to do that proactively.
We do think, and you pointed this out, AJ, that we're going to see that growth rate begin to moderate as we move into the second half of the year simply because we saw that step up in the second half of last year. In our discussions with our consultant, what we're seeing in our program apparently is pretty consistent with the peer group that's out there.

AJ Rice

Okay, and then the follow-up question, I know last year about this time, there was some noise in the numbers with the Palmetto audits and the TPE program, and how that was playing out. Any updated thoughts on where all that stands at this point and, are you back to sort of a normal situation, pretty much here?

Douglas Coltharp

I think there's the potential for some of the same dynamic to exist. And so this is the interplay specifically with Palmetto between RCD and Alabama and TPE. And as a reminder, Palmetto is our largest Mac. They're responsible for approximately 80% of our overall hospitals, including the seven that we have in Alabama.
And so, they remain consumed with the RCD program in Alabama under which, by the way, our performance has gotten better, but it is not where it ought to be and it remains a lot of hand to hand combat in trying to overcome very inconsistent treatment by Palmetto on those claims. But with regard to TPE, what we've seen at least since RCD has been in place.
Is that they seem to lack the capacity to run a consistent TPE program and administer RCD, and so the TPE activity at least last year proved to be very lumpy. We have left some room for that kind of lumpiness in our assumption regarding bad debt for the full year. As a corollary to that, I'll remind you we had that big step up when those claims were selected by Palmetto under TPE for review of the second quarter.
But what we've seen is those have played out over a multi-quarter period of time is that our recovery rate against those claims or our success rate against those claims selected from review has been highly favorable.
So there's the chance that you might see a blip, just based on our reserve methodology if we see the same kind of pattern under TPE that we saw last year, but I don't think it causes us concern that the aggregate level of bad debt expense is on the rise.

AJ Rice

Okay, thanks a lot.

Operator

(Operator Instructions)
Jared Haase, William Blair

Mark Tarr

Hey Jared.

Douglas Coltharp

Good morning, Jared.

Jared Haase

Hey, good morning. Thanks for taking the questions, and I'll echo the congrats on a strong quarter. Maybe I'll ask one on the quarter just to kind of put a fine point on things and specifically the strong EBITDA performance.
I know we've obviously focused a lot on the trends around labor, but curious if there were any other, I guess, areas in OpEx where you saw a good leverage or operating efficiency and if you could talk about the durability of some of those areas of leverage if you saw things.

Douglas Coltharp

Yeah, anytime you're running at high volumes and particularly with the density that comes with the higher occupancy rate, you're creating OpEx leverage throughout the P&L. But definitely the more pronounced, the most pronounced area of that, and it's because it's our single largest expense category was in the SW line.
I think we've pretty well already addressed our thoughts regarding the sustainability of that. We expect the as the primary measure of productivity, we expect the EPOB number to move north over the balance of the year just based on the seasonality and based also on the capacity expansions that are coming on through the course of the year.

Jared Haase

Perfect. That's helpful. And then maybe I'll go back to something you talked about in the prepared remarks, just some of the consistent performance you've had and your discharge rates and quality metrics.
And I guess I'll just ask, what are the sort of biggest drivers in your view in terms of the ability to sustain that level of performance and quality just considering how rapidly you've grown the business over the last couple of years.

Mark Tarr

Yeah, we said earlier, bringing new staff in and making sure as we add capacity that we are appropriately staffed, that we have the staff on boarded that even at our existing hospitals as we bring on new staff. We are training them and getting them oriented. So, I feel like our quality and if you just look at our trends, we continue to increase the quality, if you look at our discharge community, the reduced number of discharges being sent to skilled nursing facilities.
We always focus on patient satisfaction with our net promoter scores. So we would not be adding growth if we couldn't assure ourselves that we could show and produce the quality outcomes that we do as an organization. So I think it's very sustainable. We're very proud of where we're headed, particularly in those discharge status metrics, and we continue to focus on our with our clinical teams on how can we get incremental outcomes every day.

Douglas Coltharp

Just to underscore what Mark said there because I think it's important to note and we have experienced very rapid growth both in terms of on the same store basis and through the past expansions over a multi-year period of time. And yet we now have the highest net promoter scores and the highest employment employee engagement scores that we've ever had, and that's something that we're really proud of.

Jared Haase

That's great to hear. Thank you.

Operator

Andrew Mok, Barclays

Andrew Mok

Hi, good morning. The revenue discharge per discharge number was pretty strong in the quarter of 3.9% and finished above the underlying pricing expectations. So I know that number contemplates a number of items including core pricing, acuity, and bad debt.
Bad debt came in on the lower end of expectations, but it still looks like it's strong. Can you flush out kind of like the underlying drivers of that number and what, how we should expect that to trend for the balance of the year? Thanks.

Douglas Coltharp

Now, you're exactly right. It was, and there are a number of things that go into it. The largest ones I'd point out were that bad debt was at the low end of the range that you just cited. The second is that we had that shift in the payer mix, which I alluded to earlier, and it was not only that fee for servers grew faster than Medicare Advantage.
It's when you look more broadly at the change in the overall mix that, whereas Medicare Advantage and Medicare fee for service as a percentage of the payer mix in total for the quarter moved up 150 basis points, and those are our two highest reimbursement categories. You had managed care and Medicaid by far being our lowest, moved down 140 basis points. So that's a real favorable shift there.
We also had some favorable trends within our quality metrics that help improve our reimbursement as well. In terms of our assumptions on a go forward basis, again, we don't believe that one quarter makes a trend. So we're not assuming that this slip in the growth rates between Medicare Advantage and fee for service will sustain itself for the balance of the year.

Andrew Mok

Great. And then maybe just a follow up on share repurchase. I know you lowered the share account number and the guidance, but how are you thinking about the level of share repurchase contemplated in the guide? Did you give that number and how do you expect that to evolve over the next 12 to 18 months? Thanks.

Douglas Coltharp

We did not put out a specific number. I will note that with the share repurchases that we made in the first quarter actually slightly exceeded those that we made to all of 2024. We've talked previously about the fact that we find ourselves in the enviable position of being able to fund all or at least the vast majority of our capacity expansions with internally generated funds.
We've also been seeing, based predominantly on the growth in our EBITDA, the net leverage ratio come down. So, that is creating capacity for us to allocate more capital to share repurchases, and we think that's an appropriate utilization and a good complement to the growth CapEx we have. So I think you should anticipate continued activity under the share repurchase program.

Andrew Mok

Great. Thank you.

Operator

John Ransom, Raymond James

Douglas Coltharp

Good morning, John.

John Ransom

So, you're a key care. I won't call them peers, but the key care industry's been kind of reporting some issues and changes of behavior with Medicare Advantage. Are you guys, I mean, they've been under a lot of stress, as but are you guys see anything new or different, in your managed care negotiations, not just rate but other behavior changes, as they try to manage their cost?

Douglas Coltharp

I think from a contracting perspective we continue to have success and we're already at a very high level of moving away from per diem contracts to episodic contracts and tying those new contracts, even if they initially started a discount directly to the service reimbursement.
I will say that the overall level of price increase that we saw within our Medicare Advantage book of business in the first quarter was a bit higher than we anticipated. It came in at about 5%. Again, not ready to call that a new normal. So I don't know whether it's reflective, John, of the overall environment out there with Medicare Advantage, but we do feel like we're having good success with regard to our Medicare Advantage contract.

Mark Tarr

I would say that the whole pre-authorization process continues to be challenging, and I would say it's probably a little early to say whether or not we're seeing significant differences or new trends enter around the pre-authorization process in most of our markets.

Douglas Coltharp

And some things that we noted before continue to persist, which is the ratio of admits to referrals for Medicare Advantage is substantially below what it is for a fee for service, and we see no reason why that should exist.
And then also the number of days between a referral and ultimately a decision coming through Medicare Advantage plans is much slower than it is for fee for service, which does not endure to the benefit of the patient or the acute care hospital housing patient.

John Ransom

5% is pretty stout. Thanks guys. I appreciate it.

Mark Tarr

Thank you.

Mark Miller

Thank you.

Operator

And there are no further questions on the line at this time. I'll turn the program back to Mark Miller for any additional remarks.

Mark Miller

Thank you, operator. If anyone has additional questions, please call me at 205-970-5860. Thank you again for joining today's call.

Operator

This does conclude today's program. Thank you for your participation, and you may now disconnect.